Earlier this month the British Medical Journal published a head-to-head on the issue of whether people in the UK should pay to see a GP. On the face of it, levying a small fee or “co-payment” makes sense. Demand for GP consultations is likely to double over the next 20 years, health costs are spiralling, fees are backed by high-profile figures including a former health secretary, and fees might deter the small number of repeat attenders who account for a disproportionate burden of consultations, prescriptions and referrals.
But hold your horses. There are five compelling reasons why this seemingly innocuous measure is a bad idea.
1. It doesn’t make economic sense
Fees are often introduced to act as “price signals”. Attaching a price to GP consultations is supposed to prompt consumers to consider whether the “product” is really worth the cost, hopefully leading to fewer inappropriate consultations.
Price signalling works beautifully with plastic bags . The 5p charge doesn’t really cost that much but “nudges” shoppers into using the service only when they really need it. The issue is that health isn’t like a plastic bag. Whereas consumers are able to judge the value of a carrier bag and whether they really need it or not, it is very difficult for a layperson to evaluate the value of a medical consultation.
This “information asymmetry”, where the provider knows more about the product than the consumer (think used car sales) makes price signalling inappropriate. Is £10 worth it to get this lump looked at? Only a doctor can tell you. If people can’t judge the quality of what they are paying for, those who can’t afford the fee stop seeing their doctor, regardless of whether they need to or not.
2. It won’t save money
While fees are often proposed in order to help raise money, they can result in higher costs for the health system. Administering fees cost Germany £260m a year and resulted in 120 hours of extra work for every health centre. Where patients delay seeking medical care because of fees, GPs can’t provide early preventive advice and the underlying condition can worsen, resulting in higher treatment costs further down the line. Prevention is hugely more cost effective than treatment, and catching cancers and serious illness early results in happier, healthier patients, along with lower costs for the NHS.
Fees can lead to inappropriate use of other NHS services, such as struggling emergency departments. At £44 a consultation, GPs provide surprisingly good value for money. A ten minute GP consultation is three times cheaper than assessing the same problem in A&E.
3. They don’t reduce demand
Neither introducing nor removing GP fees has had a significant impact on demand in Germany, Ireland, or New Zealand.
Proponents have argued that fees might reduce missed appointments, as seen with table booking in the restaurant industry. This effectively creates new slots for doctors to see more patients, but there’s no evidence to suggest that fees work in this way for consultations and the vast majority of GPs don’t want to introduce fees.
It would be disingenuous to suggest that fees have absolutely no effect on demand. Small fees do seem to deter some people. Unfortunately, those most likely to forgo medical attention are vulnerable as well as low-income groups.
4. It will hurt the poor
My biggest objection to fees is that they would exacerbate Britain’s widening health inequalities. Overall, low-paid people tend to experience much worse health than the affluent. A flat-rate fee will be a larger proportion of disposable income for someone on a low-income so fees would be regressive.
It is both illogical and unjust to introduce fees that present a proportionally larger disincentive to the group of people with the worst health. Low-income groups will be hurt financially and physically as a result. Countries can introduce caps, reimbursements and exceptions to mitigate disparities, but this all adds complexity and increases administration costs. Research has also shown that relying on market forces to balance supply and demand for medical care reduces the number of health professionals working in deprived areas.
5. Co-payments are a great leap backward
Internationally, other countries want what the UK has. The NHS consistently outperforms other health systems in countries spending much higher proportions of GDP on health. Provision of care to all on the basis of clinical need rather than ability to pay is a justifiable source of national pride, if not a crowning achievement of British public policy.
Signatories of the 2015 Sustainable Development Goals recently pledged to meet a wider range of ambitious development targets including the attainment of universal health coverage. This lofty aspiration – providing quality essential services for all while protecting patients from financial costs – is a living breathing reality in the UK. Introducing fees may appear to intuitively help with mounting financial and demographic pressures. However, they won’t work, and something much more important is at stake.